Health records can be found in a paper chart or an electronic health record (EHR) Health records contain information about the patient Previous illnesses and treatments Current medical problems History of family illnesses Current medications The health record contains the data that will determine the patient’s care plan It is important that the patient’s health record contains accurate data. Documentation is the bedrock of solid communication among health care providers.
Medical notes share a consistent, logical organization Chapter 2 focuses on the organization of medical documents Health information Career Map from the American Health Information Management Association
4 The SOAP Method SOAP is an acronym for the different types of information documented by health care providers S = subjective: what the patient says O = objective: what the tests reveal A = assessment: the analysis of the subjective and objective information; performed by the health care provider P = plan: course of action for the patient Subjective: These are the complaints that the patient comes in with. Subjective information includes pain and the sensation of feeling hot or cold. Objective: This is the information gathered by the health care provider (HCP). This information could be results from tests such as vital signs (heart rate, respiratory rate, or body temperature) or other more complicated tests such as x-rays, electrocardiograms, or blood tests. Assessment: The HCP then interprets the tests and documents them here. This may be things such as, “The high body temperature along with the blood results show an increased white blood cell count, indicating a probable bacterial infection, ” or, “The electrocardiogram is normal.” Plan: This is the actions that will be taken to address the S, O, and A. For example, “Antibiotics will be started to address the bacterial infection.”
Deep Representation Learning Of Electronic Health Records To Unlock Patient Stratification At Scale
Medical records vary in length and content Medical records come in different lengths and formats. A record from the emergency department is shorter than a record from a primary care physician’s office. These components of the health record can be obtained by many health care practitioners, from the certified medical assistant to the physician. It is therefore important to understand each component of the health record.
Example Note #1: Clinic Note Discuss each area of the SOAP note presented here. This is an example of a EHR (electronic health record). SOAP notes are color-coded here to assist in learning each area, however, this is not typically done. - The blue area is the patient information, medications that the patient currently takes, and her allergies. The subjective information is also presented along with the patient’s family history. - The red area is the objective information, the tests that were performed and their results. No interpretations of this information are presented in this section. - The yellow is the assessment, which is the interpretation of the subjective and the objective information. - The green is the plan for the patient. f/u is the abbreviation for “follow up” . Words are blurred so as to avoid focus on newly presented medical terms. At the end of the chapter, the student will see these examples again, including the words that were previously blurred out.
Example Note #2: Consult Note This is an example of a paper health record. A consult is when one health care provider asks another to evaluate a patient. The patient agrees to see another health care provider that is a specialist in his or her condition. Dr. Passemon had consulted (asked) Dr. Jameson in regards to a patient, Mr. Robert Meeds. After evaluating the patient, the consulted doctor (Dr. Jameson) communicates his findings with the consulting doctor (Dr. Passemon). This is because Dr. Passemon is responsible for the patient’s overall care. Note the type of information in blue (subjective), red (objective), yellow (assessment), and green (plan).
Gynaecology Electronic Health Record Go Live
Example Note #3: Emergency Department Note This is a health record from the emergency department. Note that this record is very short and contains only the information that is needed. It does not contain information that would tell a story; it is just the facts.
Example Note #4: Admission Summary An admission summary is written when the patient is admitted to the hospital. The patient is admitted with chest pain, which could have several causes. The subjective information (in blue) is provided by the patient. The objective information (in red) are the tests that gain information from the body systems. In this health record, the assessment and plan are combined. The assessment ends with the colon, and the information after that is the plan for the assessment.
Example Note #5: Discharge Summary This example also shows that the most important information, the assessment, goes first in an operative report. Note that the preoperative and postoperative diagnoses are the same. This is not always the case, which is why these are two separate entries. Operative reports are concise and tell the story of the surgery. This record does not include the results of tests or vital signs. Vital signs are taken and recorded, but they are included in another report (usually the anesthesiologist’s record).
Compare Electronic Medical Records Ppt Powerpoint Presentation Slides Example Introduction Cpb
Example Note #6: Operative Report Example Note #7: Daily Hospital Note/ Progress Note Radiology Report Pathology Report By now I am sure you get the idea of SOAP, but here are few more examples of SOAP and medical documentation: Example #6: This example also shows that the most important information, the assessment, goes first in an operative report. Note that the preoperative and postoperative diagnoses are the same. This is not always the case, which is why these are two separate entries. Operative reports are concise and tell the story of the surgery. This record does not include the results of tests or vital signs. Vital signs are taken and recorded but in another report (usually the anesthesiologist’s record). Example #7: The health care professional (e.g., doctor, nurse practitioner, or physician assistant) makes a daily entry on the patient’s condition and any progress the patient is or is not making. It includes a physical exam because it is important to assess all body systems on a daily basis. Again, the assessment and plan are combined, but they are separated by a colon. Radiology and Pathology Reports: These reports are very short and only include information pertaining to the subject of the report.
Example Note #10: Prescription A prescription has a unique structure. The prescriber writes the name of the patient. This prescription is for medication. Prescriptions can also be for treatment, such as physical therapy. Information included: - The first line specifies the medication name and dosage. - Sig contains the instructions for the patient. The pharmacist will translate this into language that the patient can understand - Dispense tells the pharmacist the quantity of medication to give to the patient. - Refill lets the pharmacist and the patient know if they will be able to obtain more medication after the initial medication is taken. The pharmacist will substitute a generic medicine for the name brand medication unless the prescriber states that only the brand name medication should be used. In this prescription, only the name brand medication should be dispensed.
Subjective These are the problems that the patient states he/she has Those problems are then translated into medical terms This is so that you can correctly communicate the problems to all health care providers Subjective statements are those given by the patient. They are his or her “complaints.”
Introduction To Electronic Medical Records
General subjective terms: symptom noncontributory acute vs. chronic abrupt progressive vs. exacerbation febrile vs. afebrile Symptom – what the patient feels Noncontributory – patient’s symptom is not related to the current problem Acute – occurs recently, or sharp severe symptoms Chronic – a problem that occurs for a while Abrupt – occurs suddenly Progressive – worsening of symptoms Exacerbation – worsening of a condition Febrile – has a fever Afebrile – does not have a fever
General objective terms: Things that are felt: Things that are seen: Palpation alert oriented Descriptions of what is observed: Things that are heard: auscultation unremarkable percussion marked Alert – patient can answer questions; responsive, interactive Oriented – patient knows who they are, where they are, and what time it is (current date and time) Auscultation – to listen (usually with a stethoscope) Percussion – to hit or strike and then listen for the sound; the returned sound indicates the condition of the body Palpation – to feel something; how something feels can indicate its condition, be it normal or abnormal
General assessment terms: impression diagnosis differential diagnosis etiology vs. idiopathic benign vs. malignant remission Assessment is the gathering and analyzing of the facts about the patient. The facts come from the subjective and objective information. Impression – another word for assessment Diagnosis – using the subjective and objective data to determine the patient’s condition Differential diagnosis – based on the subjective and objective data, the health care professional cannot yet determine the diagnosis; for example, vague chest pain could lead to a differential diagnosis of pneumonia or a heart condition Etiology – the cause Idiopathic – no known cause Benign – not cancerous Malignant – cancerous Remission –
Structure And Functionality Of The Electronic Health Record. Layer...
Example Note #6: Operative Report Example Note #7: Daily Hospital Note/ Progress Note Radiology Report Pathology Report By now I am sure you get the idea of SOAP, but here are few more examples of SOAP and medical documentation: Example #6: This example also shows that the most important information, the assessment, goes first in an operative report. Note that the preoperative and postoperative diagnoses are the same. This is not always the case, which is why these are two separate entries. Operative reports are concise and tell the story of the surgery. This record does not include the results of tests or vital signs. Vital signs are taken and recorded but in another report (usually the anesthesiologist’s record). Example #7: The health care professional (e.g., doctor, nurse practitioner, or physician assistant) makes a daily entry on the patient’s condition and any progress the patient is or is not making. It includes a physical exam because it is important to assess all body systems on a daily basis. Again, the assessment and plan are combined, but they are separated by a colon. Radiology and Pathology Reports: These reports are very short and only include information pertaining to the subject of the report.
Example Note #10: Prescription A prescription has a unique structure. The prescriber writes the name of the patient. This prescription is for medication. Prescriptions can also be for treatment, such as physical therapy. Information included: - The first line specifies the medication name and dosage. - Sig contains the instructions for the patient. The pharmacist will translate this into language that the patient can understand - Dispense tells the pharmacist the quantity of medication to give to the patient. - Refill lets the pharmacist and the patient know if they will be able to obtain more medication after the initial medication is taken. The pharmacist will substitute a generic medicine for the name brand medication unless the prescriber states that only the brand name medication should be used. In this prescription, only the name brand medication should be dispensed.
Subjective These are the problems that the patient states he/she has Those problems are then translated into medical terms This is so that you can correctly communicate the problems to all health care providers Subjective statements are those given by the patient. They are his or her “complaints.”
Introduction To Electronic Medical Records
General subjective terms: symptom noncontributory acute vs. chronic abrupt progressive vs. exacerbation febrile vs. afebrile Symptom – what the patient feels Noncontributory – patient’s symptom is not related to the current problem Acute – occurs recently, or sharp severe symptoms Chronic – a problem that occurs for a while Abrupt – occurs suddenly Progressive – worsening of symptoms Exacerbation – worsening of a condition Febrile – has a fever Afebrile – does not have a fever
General objective terms: Things that are felt: Things that are seen: Palpation alert oriented Descriptions of what is observed: Things that are heard: auscultation unremarkable percussion marked Alert – patient can answer questions; responsive, interactive Oriented – patient knows who they are, where they are, and what time it is (current date and time) Auscultation – to listen (usually with a stethoscope) Percussion – to hit or strike and then listen for the sound; the returned sound indicates the condition of the body Palpation – to feel something; how something feels can indicate its condition, be it normal or abnormal
General assessment terms: impression diagnosis differential diagnosis etiology vs. idiopathic benign vs. malignant remission Assessment is the gathering and analyzing of the facts about the patient. The facts come from the subjective and objective information. Impression – another word for assessment Diagnosis – using the subjective and objective data to determine the patient’s condition Differential diagnosis – based on the subjective and objective data, the health care professional cannot yet determine the diagnosis; for example, vague chest pain could lead to a differential diagnosis of pneumonia or a heart condition Etiology – the cause Idiopathic – no known cause Benign – not cancerous Malignant – cancerous Remission –
